Nursing Elites

1. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?

• A. Pallor
• B. Increased temperature
• C. Dyspnea
• D. Involuntary muscle spasms

Correct answer: C

Rationale: Dyspnea indicates a potential complication such as pneumothorax or incorrect catheter placement, requiring immediate attention. Pallor may indicate anemia but is not as urgent as dyspnea in this context. Increased temperature could be a sign of infection but is not as critical as respiratory distress. Involuntary muscle spasms are not directly related to central venous catheter placement and are of lower priority compared to respiratory issues.

2. The nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is to

• A. enhance absorption of the medication
• B. ensure that the entire dose of medication is given
• C. provide more even distribution of the drug
• D. prevent the drug from tissue irritation

Correct answer: D

Rationale: The correct answer is D. Deep injection helps to prevent tissue irritation caused by iron, which can be damaging to tissues. Option A is incorrect because deep injection does not primarily aim to enhance absorption, but rather to prevent tissue irritation. Option B is incorrect as the route of administration does not determine whether the entire dose is given. Option C is incorrect because the even distribution of the drug is not the main purpose of deep injection in this context.

3. A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?

• A. Notify the healthcare provider
• B. Readjust the traction
• C. Administer the ordered PRN medication
• D. Reassess the foot in fifteen minutes

Correct answer: A

Rationale: In this situation, a pale foot with the absence of a pulse indicates compromised circulation, which is a critical emergency. The nurse should immediately notify the healthcare provider to address the circulation issue promptly. Reading the question and understanding the urgency is vital. Readjusting the traction, administering PRN medication, or waiting to reassess the foot in fifteen minutes are not appropriate actions when a child is experiencing compromised circulation.

4. A nurse is reinforcing teaching about food choice with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching?

• A. I will give my child peanut butter and mashed egg whites.
• B. I will give my child rice cereal and crackers.
• C. I will give my child pureed liver and strained pears.
• D. I will give my child applesauce and green peas.

Correct answer: A

Rationale: The correct answer is A because peanut butter and egg whites are not recommended for infants under 12 months due to the risk of choking and allergies. Choices B, C, and D are appropriate food choices for an 8-month-old infant. Rice cereal, crackers, pureed liver, strained pears, applesauce, and green peas are all suitable options for introducing solid foods to infants.

5. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate?

• A. Pulverize all medications into a powdery condition
• B. Squeeze the tube before using it to break up stagnant liquids
• C. Cleanse the skin around the tube daily with hydrogen peroxide
• D. Flush adequately with water before and after using the tube

Correct answer: D

Rationale: For a client with a percutaneous endoscopic gastrostomy (PEG) tube, flushing the tube adequately with water before and after use is essential. This action helps prevent clogging and ensures the proper administration of feedings and medications. Choice A is incorrect because pulverizing all medications into a powdery condition is not necessary for PEG tube administration. Choice B is incorrect as squeezing the tube to break up stagnant liquids may damage the tube. Choice C is incorrect because cleansing the skin around the tube daily with hydrogen peroxide can be too harsh and lead to skin irritation.

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